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Reviewing and Summarizing Medical Records

One of the most time-consuming tasks is handling the medical records for a legal claim in your office. There’s a lot of information that goes into these records, and not all of it is necessary for your claim. However, this information needs to be thoroughly gone through to ensure that nothing important slips through the cracks. Knowing these tips can help to make this process a bit smoother for you and your staff that handles the reviewing and summarizing of your client’s medical records.

Summarizing Medical Records

Review Typewritten Records

The first set of documents that you want to go through is the typewritten records. These are usually rather easier to read than handwritten and include official documents from the hospital, doctor’s office, laboratories and more. Be on the lookout for discharge summaries, consult reports, objective findings, radiology reports, follow up care instructions, lab tests, diagnoses, and medications.

Review Handwritten Records

Handwritten records can be hard to deal with when it comes to deciphering handwriting, but these often have great information in them. You may find that some places don’t give out typewritten intake or discharge papers along with other information. Nurses notes are often handwritten along with chiropractors’ records. You’ll want to go through this information to find any details that help your client’s claim.

Summaries

Once you’ve located the pertinent documents that have the information needed for the summary, it’s time to write it up. You’ll want to document every detail that you’ve found in the records into your summary. Typically, you’ll want to do this in chronological order. A step that you might miss is a final review. You’ll want to go over the documents to make sure that you’re not missing anything, and that you’ve included everything in your summaries final draft.

Let the Professionals Step In

Delegation is a skill that many struggle with, but in order to keep your workday manageable, delegation can be necessary. Reviewing and summarizing medical records is one task that is beneficial for you to delegate to a professional service. The amount of time it can take you or your legal staff to work on this task takes away from your other important tasks. A professional summary writer is able to get it done efficiently, and because of their expertise, is able to get the pertinent information necessary for this claim.

Contact LM Summary Services today about how we can change the way that your office handles medical summaries.

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